The Surgery of the Skull and Brain by L Bathe Rawling

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Title: The Surgery of the Skull and Brain

Author: L. Bathe Rawling

Release Date: January 29, 2020 [EBook #61267]

Language: English

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OXFORD MEDICAL PUBLICATIONS

THE SURGERY OF

THE SKULL AND BRAIN

PUBLISHED BY THE JOINT COMMITTEE OF

HENRY FROWDE AND HODDER & STOUGHTON

AT THE OXFORD PRESS WAREHOUSE

FALCON SQUARE, LONDON, E.C.

OXFORD MEDICAL PUBLICATIONS

THE SURGERY OF

THE SKULL AND BRAIN

BY

L. BATHE RAWLING, F.R.C.S.

HENRY FROWDE
Oxford University Press

HODDER & STOUGHTON

Warwick Square, E.C.

SURGEON, WITH CHARGE OF OUT-PATIENTS, SENIOR DEMONSTRATOR OF PRACTICAL SURGERY

DEMONSTRATOR OF OPERATIVE SURGERY, ST. BARTHOLOMEW’S HOSPITAL

LATE HUNTERIAN PROFESSOR, ETC.

LONDON

1912

OXFORD: HORACE HART

PRINTER TO THE UNIVERSITY

PREFACE

This work on the Surgery of the Skull and Brain is based on experience derived, and on research carried out,

during the past ten years.

Cranio-Cerebral Surgery, though still in its infancy, has progressed with leaps and bounds during the past few

years. This book represents the most modern aspects of the case and is brought up to date by means of a recent visit to
some of the leading surgical clinics of the United States of America.

I have realized to the full the difficulties of the task which I have undertaken, but have every confidence that they

have been overcome and that a reasonable measure of success has been obtained. With this anticipation, this work on
the Surgery of the Skull and Brain is offered to the Profession.

L. BATHE RAWLING.

April 1912.

CONTENTS

PAGE

CHAPTER I

Cranio-Cerebral Topography
1

CHAPTER II

The Special Technique in Operations on the Skull and Brain
10

CHAPTER III

Cephaloceles, Birth-fractures and Hæmorrhages, Hydrocephalus and Dermoids
31

CHAPTER IV

Fractures of the Skull
68

CHAPTER V

Intracranial Injuries. Extra- and Sub-dural Hæmorrhages. Injury to the Brain
135

CHAPTER VI

The Remote Effects of Head-injury
182

[v]

[vi-
vii]

CHAPTER VII

Tumours of the Brain
210

CHAPTER VIII

The Infective Diseases of the Brain and Meninges: Abscess of the Brain, Meningitis, Lateral and Cavernous

Sinus Thrombosis, Hernia Cerebri
247

CHAPTER IX

Bullet-wounds of the Skull and Brain
294

CHAPTER X

Trigeminal Neuralgia
306

CHAPTER XI

Tumours of the Skull-bones
325

INDEX
335

LIST OF ILLUSTRATIONS

FIGS.
PAGES

1 and 2. Cranio-cerebral topography
2, 3

3. The cortical motor and sensory areas
8

4 and 5. The scalp-tourniquet
14, 15

6. Cushing’s ‘clips’
18

7. Hudson’s trephine
20

8. The hand-trephine
21

9 and 10. The technique of trephining
22

11-16. Instruments used in trephining
23, 24

17-19. The formation of an osteoplastic flap
26, 27

20. An occipital cephalocele
33

21. A cephalocele over the anterior fontanelle
35

22. An occipital cephalocele
37

23. A depressed birth-fracture
45

24 a and b. A case of depressed birth-fracture, before and after operation
47

25. To illustrate the effects and position of a birth-hæmorrhage
53

26. The author’s operation for Hydrocephalus internus
64

27. The conversion of Hydrocephalus internus into cephalocele
65

28. Illustrating the lines along which forces received on the vault are transmitted to the base
69

29 a and b. The base of the skull and the base as seen on transillumination
70, 71

30. Plan of the base of the skull
77

31. To illustrate the relation of basic fractures to cranial nerves
81

32-37. The lines pursued by basic fractures
83-8

38 a and b. To illustrate the probable source of profuse hæmorrhage from the ear
97

39. To show the relation of a typical basic fracture to the middle ear and its adjuncts
103

40 and 41. To show the relation of basic fractures to the petrous bone
104, 105

42. A comminuted fracture of the skull
112

43 a and b. An explosive fracture of the vault of the skull
113

44. A temperature chart illustrating the changes in temperature observed in head-injuries
117

45-48. Intermusculo-temporal cerebral decompression
122, 123

49 a and b. The elevation of a depressed fracture of the vault
131

50 a and b. The inner aspect of the skull and the same seen on transillumination
137

51. To illustrate compression of the brain as produced by an extra-dural hæmorrhage from the middle

meningeal artery
141

52 a and b. The operative treatment of middle meningeal hæmorrhage
144, 145

53. A basic fracture with laceration of both carotid arteries
148

[viii]

[ix]

[x]

54. A basic fracture with laceration of the cavernous sinus
149

55. A basic fracture with laceration of both lateral sinuses
151

56 a and b. The operative treatment of subdural hæmorrhage
156, 157

57. The areas concerned in speech expression
163

58. The cortical motor and sensory areas
165

59. The König-Müller osteoplastic flap
197

60. The author’s method of covering in a gap in the skull
199

61. A case of traumatic orbital aneurysm
207

62. A glioma of the brain
211

63. A sarcoma of the brain
211

64. An endothelioma of the dura mater
212

65. A fibroma of the dura mater
212

66. An acoustic tumour
213

67. Symmetrical tuberculomata
214

68. The cortical motor and sensory areas
220

69. The visual paths
223

70. A pituitary tumour
226

71 a, b and c. The exposure of a tumour by osteoplastic flap
230, 231

72. Combined flap formation and decompression
235

73 a, b, c and d. The exposure of a cerebellar tumour by craniectomy
239-41

74 a and b. To illustrate the extension of disease from the tympanic cavity and the surgical anatomy of

that region (after Hunter Tod)
251

75. A large right-sided temporo-sphenoidal abscess
256

76. To illustrate the pressure effects of a temporo-sphenoidal abscess
257

77. A cerebellar abscess
259

78. To illustrate diagrammatically the symptoms observed in cerebellar abscess formation (after Luciani)
261

79. The exposure of a temporo-sphenoidal abscess
265

80. The ‘radical’ mastoid operation (after Hunter Tod)
269

81. Exploration for a temporo-sphenoidal abscess (after Hunter Tod)
270

82. Exploration for a cerebellar abscess (after Hunter Tod)
271

83. A fracture of the anterior fossa which was followed by the development of meningitis
275

84. Basal meningitis secondary to temporo-sphenoidal abscess
277

85 a and b. To illustrate the exposure of the lateral sinus (after Hunter Tod)
285

86. A case of Hernia cerebri and the abscess after removal
292

87. Diagrammatic illustration of the three forms of ‘gutter’ fracture
297

88. Diagrammatic representation of the effects produced on bone and brain by a perforating bullet-

wound
299

89 a and b. Sheen’s bullet probe, forceps, and telephone bullet-detector
302, 303

90. To illustrate the operations on the Gasserian ganglion
317

91. To illustrate the operations for exposure of the Gasserian ganglion
321

92. Ivory exostoses of the skull
326

93. The development of the frontal bone
327

94. An exostosis of the orbit
330

95. An extrinsic sarcoma of the skull
331

96. An intrinsic sarcoma of the skull
333

THE SURGERY OF

THE SKULL AND BRAIN

CHAPTER I

CRANIO-CEREBRAL TOPOGRAPHY

[xi]

[1]

The superior longitudinal sinus.

The lateral sinus.

The surgeon who is called upon to carry out operations on the skull and brain must possess an accurate

knowledge of the anatomy of the parts involved. Added to this, he must have at his command some simple method of
depicting on the surface of the skull the more important structures.

The more complicated systems of cranio-cerebral topography are of little practical value to the surgeon. Simplicity

is essential, and the following outline will be found to furnish an adequate practical guide.

Firstly, the skull can be divided into two lateral halves by the surface-marking of the superior longitudinal venous

sinus.

This sinus originates at the crista galli and, passing backwards along the

attached margin of the falx cerebri, terminates at the internal occipital protuberance. It may be represented by a line
drawn from the base of the nose (the nasion), over the vertex of the skull, to the external occipital protuberance (the
inion)—this line corresponding in its course to the occasionally persistent metopic suture between the two halves of the
frontal bone, to the sagittal suture between the parietal bones, and to the middle line of the upper or tabular portion of
the occipital bone.

Secondly, each lateral half of the skull can be subdivided into supra- and infratentorial regions by a line which

marks the external attachment of the tentorium cerebelli; in other words, by the line of the lateral sinus.

This sinus is represented by a line presenting a slight upward convexity, which is drawn from

the external occipital protuberance to the upper and posterior part of the mastoid process of the temporal bone.

[2]

FIG. 1. CRANIO-CEREBRAL TOPOGRAPHY. 1, THE NASION; 2, THE INION; 3, THE MID-POINT BETWEEN NASION

AND INION; 4, THE ROLANDIC FISSURE; 5, THE SUPERIOR TEMPORAL CREST; 6, THE INFERIOR TEMPORAL CREST; 7, THE
SYLVIAN POINT; 8, THE ANTERIOR HORIZONTAL LIMB OF THE SYLVIAN FISSURE; 9, THE VERTICAL LIMB OF THE SYLVIAN
FISSURE; 10, THE POSTERIOR HORIZONTAL LIMB OF THE SYLVIAN FISSURE; 11, THE PARIETAL PROMINENCE; 12, THE
MALAR TUBERCLE; 13, THE LAMBDA; 14, THE FIRST TEMPORO-SPHENOIDAL SULCUS; 15, THE EXTERNAL PARIETO-
OCCIPITAL SULCUS; 16, THE LATERAL SINUS; 17, 17, 17, THE LEVEL OF THE BASE OF THE CEREBRUM; 18, THE EXTERNAL
AUDITORY MEATUS; 19, 19, REID’S BASE-LINE. (Reproduced, by the permission of Mr. H. K. Lewis, from the
author’s work on ‘Landmarks and Surface-markings’.)

Larger illustration (top)

Larger illustration (bottom)

[3]

The infratentorial region.

The supratentorial region.

(a) The external angular frontal process.

(b) The malar tubercle.

(c) The temporal crest.

(d) The parietal prominence.

(e) The zygoma.

FIG. 2. CRANIO-CEREBRAL TOPOGRAPHY. 1, 1, REID’S BASE-LINE; 2, 2, A LINE PARALLEL TO THE ABOVE AT THE

LEVEL OF THE SUPRA-ORBITAL MARGIN; 3, THE MIDDLE MENINGEAL ARTERY; 4, THE ANTERIOR BRANCH; 5, 5, 5, THE
THREE SITES FOR TREPHINING; 6, THE POSTERIOR BRANCH; 7, THE SITE FOR TREPHINING; 8, THE POINT FOR TREPHINING
TO REACH THE DESCENDING HORN OF THE LATERAL VENTRICLE; 9, THE LATERAL SINUS; 10, THE INION; 11, THE MASTOID
PROCESS; 12, MACEWEN’S SUPRAMEATAL TRIANGLE; 12
a, THE MASTOID ANTRUM; 12b, THE FACIAL NERVE; 13, THE

SUPRAMEATAL AND SUPRAMASTOID CRESTS; 14, 14, THE TEMPORAL CREST; 15, THE TEMPORAL FOSSA; 16, THE
EXTERNAL ANGULAR FRONTAL PROCESS; 17, THE TENDO-OCULI ATTACHMENT; 18, THE LACHRYMAL GROOVE.
(Reproduced, by the permission of Mr. H. K. Lewis, from the author’s work on ‘Landmarks and Surface-
markings’.)

Larger illustration (top)

Larger illustration (bottom)

The cerebellum lies wholly beneath the tentorium cerebelli, and it is obvious that, in

operations carried out over this portion of the brain, the surgeon is limited in his field of exposure, above by the line of
the lateral sinus, and on either side by the posterior border of the mastoid process. The division between the halves of
the cerebellum may be represented by a line drawn vertically downwards from the external occipital protuberance to
the nuchal region. This line also represents the surface-marking of the occipital sinus and falx cerebelli.

Brief allusion must be made to certain landmarks that aid in the representation of

structures situated in this region:—

The suture between the external angular frontal process and the

corresponding process of the malar bone lies immediately above the central point of the outer border of the orbital
cavity.

A slight prominence on the posterior border of the frontal process of the malar bone,

about 1⁄4 inch below the external angular frontal process.

A prominent ridge that is directed upwards and backwards from the external angular

frontal process. The crest cuts across the lower portion of the parietal bone, passing below the parietal prominence, and
curves downwards towards the upper and posterior portion of the mastoid process. It terminates by becoming
continuous with the upper root of the zygomatic process. The crest consists of two parts, the upper and lower temporal
crests. To the upper is attached the temporal fascia, to the lower the temporal muscle. The lower crest is almost
invariably the more prominent.

The central and most prominent part of the parietal bone. It indicates the point at

which ossification commenced, and lies about 3⁄4 inch above the termination of the posterior horizontal limb of the fissure
of Sylvius.

When traced in the backward direction, the zygoma is found to divide immediately in front of the

ear into three roots, of which the anterior, merging into the eminentia articularis, and the middle, aiding in the formation
of the post-glenoid process, are of no practical utility in surface-marking. The upper or posterior root sweeps
backwards above the external auditory meatus to become continuous with the suprameatal and supramastoid crests, the
former of which forms the upper boundary of Macewen’s suprameatal triangle, a triangular depression at the upper
and posterior border of the external auditory meatus. This triangle may be taken as representing the opening of the
mastoid antrum into the middle ear.

These landmarks having been determined, the following structures may be mapped out on the surface of the skull.

[4]

[5]

The middle meningeal artery.

The lower limit of the cerebrum.

The Sylvian point and fissure.

The fissure of Rolando.

The parieto-occipital and first temporo-sphenoidal fissures.

The cortical motor and sensory areas.

This artery is given off from the internal maxillary; after a short extra-cranial

course it enters the skull through the foramen spinosum, and soon divides into two main terminal branches. The site of
division corresponds to a point situated just above the centre of the zygoma.

The anterior branch passes at first in a forward and upward direction towards the anterior inferior angle of the

parietal bone, and then turns upwards and backwards towards the vertex of the skull. The main ‘danger zone’ in the
course of this vessel may be mapped out by taking points which lie respectively 1, 11⁄2, and 2 inches behind the external
angular frontal process and an equal distance above the upper border of the zygoma. A line uniting these three points
represents that part of the anterior division of the middle meningeal artery which is most liable to injury and which
therefore most frequently requires exposure.

The uppermost point may, however, be regarded as the ‘site of election’ for exposure of the artery, as, in

trephining over either of the two lower points, difficulty may be experienced in the removal of the disk of bone, since the
posterior border of the great wing of the sphenoid tails off on to the anterior inferior angle of the parietal bone in such a
manner that to effect a clean removal of the disk is often impossible. Another disadvantage to trephining low down lies
in the fact that in about 30 to 40 per cent. of cases the artery occupies, in that situation, a canal in the bone.

The posterior branch passes almost horizontally backwards, parallel to the zygoma and supramastoid crest,

towards the posterior inferior angle of the parietal bone. The vessel can readily be exposed by trephining over the point
at which a line drawn backwards from the upper border of the orbit, parallel to Reid’s base-line,[1] cuts another line
directed vertically upwards from the posterior border of the mastoid process.

Both branches of the middle meningeal artery possess important relations to the cortex cerebri, the anterior branch

passing upwards in relation to the precentral or motor area, traversing, from below upwards, the motor speech area (on
the left side of the head), the centres for the movements of the face, upper extremity, trunk, and lower extremity. The
posterior branch, on the other hand, passes backwards in relation to the temporo-sphenoidal lobe, one of the so-called
‘silent areas’ of the brain. Throughout their course the middle meningeal vessels lie between the dura mater and the
bone.

The lower limit of the cerebrum can be mapped out in the following manner:

From a point situated about 1⁄2 inch above the nasion a line is drawn outwards which follows the curve of the upper
border of the orbit as far as the external angular frontal process, thence curving upwards and backwards to the Sylvian
point (see below). The temporo-sphenoidal lobe sweeps forwards to the posterior border of the malar bone, and its
lower limit lies practically flush with the upper margin of the zygoma. At and behind the ear the lower limit of the
cerebrum corresponds to the suprameatal and supramastoid crests, subsequently following the curve of the lateral sinus
from the mastoid process to the external occipital protuberance.

The Sylvian point represents the site of divergence of the three limbs of the

Sylvian fissure. It lies 11⁄4 inches behind the malar tubercle and 11⁄2 inches above the upper border of the zygoma. The
main posterior horizontal limb passes backwards and upwards to a second point situated 3⁄4 inch below the parietal
prominence.

The vertical limb is directed upwards for about 1 inch, whilst the anterior horizontal limb passes forwards for about

the same distance.

This, from a surgical point of view, the most important fissure of the brain, is

represented as follows: A point is taken in the median antero-posterior line which lies 1⁄2 inch behind the mid-point
between nasion and inion, and from this point a line is drawn, for 31⁄2 to 4 inches, towards the mid-point of the zygoma.
This line is inclined to the median antero-posterior line at an angle of 671⁄2° (three-quarters of a right angle).

In the representation of these two fissures, two

points require to be determined—the malar tubercle and the lambda. Allusion has already been made to the former; the
latter is usually readily located as the point of intersection of the sagittal and lambdoid sutures. A line uniting these two
points corresponds in its middle third to the temporo-sphenoidal fissure, and in its posterior inch or so to the external
parieto-occipital sulcus, a fissure separating the occipital and parietal lobes of the brain.

The researches of Sherrington and Grünbaum,[2] Campbell,[3] and

others tend to show that the cortical motor areas are situated entirely anterior to the central fissure or fissure of
Rolando, extending above well over on to the mesial aspect of the brain, though not so far as the calloso-marginal
fissure, and in the downward direction to within a short distance of the fissure of Sylvius. In the posterior direction the
motor area includes the anterior boundary and part of the bottom of the fissure of Rolando, whilst in front it spreads, by
means of gyri annectantes, on to that part of the brain which lies anterior to the precentral sulcus. The anterior
termination is indefinite, but the motor strip is, on an average, not more than 3⁄4 inch in breadth.

The genua of the Rolandic fissure are said to bear a more or less definite relation to the motor areas. In my

experience, however, they are too variable, and any importance which might obtain is further diminished by the fact that
the surgeon should never rest content with that limited exposure of the brain which was so much in vogue till recent
years. The suspected region is widely exposed by osteoplastic flap, and if doubt exists as to the particular part of cortex
exposed the question is accurately settled by faradization.

This motor strip corresponds, from above downwards, to the movements of the contralateral lower extremity (toe

to hip), trunk, upper extremity (shoulder to fingers), neck and face. It is a point of some general utility to bear in mind
that the temporal crest intervenes approximately between the regions responsible for the movements of the upper
extremity (above the crest) and those for the movements of the head and face (below the crest).

[6]

[7]

[8]

[1]

[2]
[3]

Preparatory treatment.

FIG. 3. THE CORTICAL MOTOR AND SENSORY AREAS.

On the left side of the head—in normal right-handed individuals—the motor speech area of Broca corresponds

to the third left frontal convolution, in the angle between the anterior and posterior horizontal limbs of the Sylvian fissure.

The ‘primary registration’ of ‘common sensation’ occurs in the post-central gyrus, immediately posterior to the

fissure of Rolando. This tactile area occupies a position behind the fissure of Rolando similar in extent to that occupied
by the motor area in front. It commences at the bottom of the fissure of Rolando and extends backwards over rather
more than half the exposed area of the post-central convolution. It reaches down to near the Sylvian fissure and extends
over on to the mesial aspect of the brain. Furthermore, it is probable that sensation in any given part lies on more or less
the same level as the corresponding motor area.

Immediately posterior to the tactile area and occupying the posterior and upper part of the post-central

convolution, the area responsible for muscle-sense is situated.

Stereognosis—memory pictures, object perception, &c.—is referred to the superior parietal lobe.
Primary visual impressions are received in the occipital lobe, more especially on the mesial aspect thereof.
Finally, the four areas concerned in speech—motor speech, writing, reading, and hearing—are anatomically

separated from one another and yet closely associated, so much so that one can hardly be involved without the other.
The motor speech centre of Broca has already been mentioned as occupying—in right-handed individuals—the
posterior part of the third left frontal convolution. Writing lies immediately above and in front, in the posterior part of the
middle frontal gyrus, auditory impressions are received in the posterior and upper part of the first temporo-sphenoidal
lobe, whilst the power of reading is dependent on the integrity of the supramarginal and angular gyri (see also Fig. 57).

Smell and Taste lie in close relation to the anterior pole of the temporo-sphenoidal lobes.

Reid’s base-line is a line drawn around the skull, starting in front at the lower border of the orbit and passing through

the central point of the external auditory meatus.

Proceedings and Philosophic Transactions of the Roy. Soc., 1901.
Localization of Cerebral Function. Camb. Univ. Press, 1905.

CHAPTER II

THE SPECIAL TECHNIQUE IN OPERATIONS ON THE SKULL AND BRAIN

Where possible at least two or three days should elapse between the admission of the

patient and the day of operation. During this period the patient should be confined to bed with all possible cheerful
surroundings. The bowels are regulated and the diet restricted.

The extent to which the scalp should be shaved and the time at which this procedure should be carried out vary

according to the circumstances of the case. Much depends on the sex and age of the patient and the nature of the

[9]

[10]

Precautions against the development of shock.

The anæsthetic.

The position of the patient.

Preparation of the operative field.

proposed operation. Insomuch, however, as it is always inadvisable to prolong the period of anæsthesia, it follows that
the shaving should be carried out previous to the operation. With regard to extent, each case must be judged on its own
merits. For instance, considerable concession must be made in the case of a young woman on whom the surgeon
proposes to carry out a subtemporal decompression operation, and in the case of a neurotic or elderly patient who is
the subject of trigeminal neuralgia. There can, however, be no question that the limitation of operative field advocated
by some surgeons is fraught with considerable risk from the point of view of wound infection.

If the question be discussed with the patient the surgeon will find the ground cut away from beneath his feet, and

that he has to make considerable and inadvisable concessions. Taking everything into consideration, although it is
seldom necessary to shave the whole head, I am accustomed to order such preparation as will allow of a very wide
margin. To shave the whole head is not only unnecessary but is also exceedingly distasteful to the patient. The front,
back, or side of the head should be prepared only—on the morning of the operation, so as to allow of a comfortable
night’s rest. After shaving, the scalp is thoroughly cleansed with soap and water, and the head surrounded by a sterilized
towel. The final skin sterilization is carried out when the patient is under the anæsthetic.

The iodine method has always given satisfactory results, the skin being painted, half an hour previous to operation,

with a 21⁄2 per cent. solution of iodine, and again after the administration of the anæsthetic. Still, I cannot avoid a certain
penchant for the older method—sponging with ether to remove the fats, washing with a 1 in 500 spirit solution of
biniodide of mercury, and finally douching with a weaker mercury solution.

It is almost inevitable that all serious head-operations should

be associated with some degree of shock, though, from my experience, I am convinced that, with due precautions, it is
far less serious than is generally supposed. The development of shock is very largely dependent on the amount of blood
lost during the operative procedures. The various methods adopted to control hæmorrhage are enumerated later. In
addition, attention should be paid to the following details:—

1. Half an hour before the operation an injection of a quarter of a grain of morphia should be given

hypodermically. The addition of one-hundredth of a grain of atropin, recommended by some surgeons, interferes
somewhat, by its action on the pupil, with the data deemed necessary for the administration of the anæsthetic.

2. The theatre should be maintained at a temperature between 65 and 75 degrees Fahrenheit. The table should be

suitably warmed.

3. The patient’s body should be covered with warm blankets, and, in the more serious cases, the lower extremities

may be bandaged, from below upwards.

It has been recommended that the brain, if exposed, should be protected from the cooling effects of the

atmosphere by irrigation with saline solution at a temperature between 110 and 115 degrees Fahrenheit. Personally I
prefer to keep the operative field as dry as possible.

An assistant should be told off, whose duty lies in keeping a record both of blood-pressure and pulse-rate. The

lowering of blood-pressure is the surest guide to the surgeon of approaching danger.

It is often considered that rapidity of operation is essential. There can be no greater error. To ensure success the

utmost care must be taken to control the loss of blood, for which it is essential that each step of the operation should be
carried out deliberately and carefully.

Needless to say, it is essential that the surgeon should have at his disposal an anæsthetist of

great experience in head operations.

Ether is regarded with favour in the United States, and in other countries, but we prefer chloroform on the ground

that, by its lowering effect on the blood-pressure, there is less venous oozing, and added to this there is probably less
tendency to post-operative vomiting. I have recently had the opportunity of seeing the open ether method as carried out
in the States, on one occasion for an operation lasting four hours, and in this and in other cases the patient left the
operation table in excellent condition, recovering also rapidly from the effects of the anæsthetic.

The lowering of blood-pressure as produced by chloroform might be advanced as an argument against the use of

that drug, shock being the greatest danger to be feared in these operations. Still, I must say that I prefer chloroform so
long as it is administered by a skilled anæsthetist.

In any case, it is advisable to have oxygen ready to hand.

Special tables have been invented and special positions advised. Thus, the dental-

chair position is recommended for operations on the Gasserian ganglion, and, in cerebellar operations, it is urged that
the patient should be turned on his face, the forehead resting on a tripod, the shoulders on supports fastened to the head
of the table. Personally, I do not consider that any special arrangements are required in the majority of cases. Much can
be done with sand-bags and firm pillows. Even in the exposure of one cerebellar hemisphere I prefer to utilize the semi-
prone position.

In bilateral cerebellar exposure, however, the patient must be placed on his face, the forehead resting on special

supports, and the shoulders on props or pillows so as to allow of free entry of air into the chest. In such cases the
anæsthetic is administered from below.

I am not enthusiastic over the so-called dental-chair position, but the operating table should be constructed in such

a manner that the head and shoulders of the patient can be well raised, the body being inclined to the floor at an angle of
about 30-40 degrees.

When the patient is fully under the anæsthetic, the final cleansing of the scalp

is carried out and the operative field cut off from all possible sources of infection. In the States, in Cushing’s clinic, the
anæsthetist is completely covered with a large sterilized sheet, which is fastened to the head of the patient. In this
country we prefer that our anæsthetist should have full knowledge of the progress of the operation, and I think that the
advantages are with us. In any case, the whole head is enveloped in gauze, two or three layers thick and about 18

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FIG. 4. THE SCALP-TOURNIQUET. Front View.
FIG. 5. THE SCALP-TOURNIQUET. Back View.

Hæmorrhage from vessels of the scalp.

inches square. This sheet is thrown over the patient’s head and maintained in position by means of the scalp-tourniquet
(see pp. 14, 15). Around this sterilized towels are arranged, either fastened to one another or stitched to the scalp.
When the operation is conducted in the temporal region the towels, unless fastened to the skin by means of a few
sutures or safety-pins, tend to become displaced, and by so doing add to the risk of wound infection.

THE CONTROL OF HÆMORRHAGE

All surgeons must have appreciated the difficulty attendant on the

application of forceps to, and the ligature of, divided scalp-vessels. The patient may lose a considerable quantity of
blood, and much valuable time will be wasted before the more essential part of the operation is commenced. All this
can, under ordinary circumstances, be avoided by the use of the scalp-tourniquet. As used by Cushing it consists of a
rubber ring fashioned after the style of an Esmarch’s tourniquet, encircling the head and passing from the lower frontal
region in front, above the ears, to the lower occipital region behind. A median tape, passing from glabella to occiput,
prevents any tendency for the tourniquet to slip down over the eyes, at the same time acting as a convenient landmark
for the superior longitudinal sinus.

The tourniquet, when applied with the correct pressure, should, under ordinary circumstances, completely control

all hæmorrhage from the divided scalp-vessels. It should be noted, however, that bleeding will be rather increased than
otherwise if the tourniquet be so loosely applied as to impede the venous return without compressing the scalp arteries.
A little experience will soon enable the operator to gauge the requisite pressure.

There is one other exception to the satisfactory working of the scalp-tourniquet. In the presence of a superficial

cerebral tumour, especially when of a malignant nature, the normal communication between the intra- and extra-cranial
vascular systems may be so exaggerated that those scalp-vessels which receive diploic and emissary venous
communications will give rise to some trouble. This difficulty should be overcome—not by rapidity in the formation and
turning down of the flap—but by clipping each vessel as exposed or divided, by the application of pressure and by
foraminal occlusion (see also p. 17).

I found Cushing’s tourniquet rather inconvenient in its application, and, after various modifications, am accustomed

to use the one depicted in the illustration. It consists of two flat metal bands connected posteriorly by a strong rubber
connecting link, the two bands passing in front through a metal fixation piece possessing a screw which, when tightened
up, allows of the maintenance of the desired pressure. The median tape, previously mentioned, helps to keep the
tourniquet in position.

The tourniquet is applied as follows: the whole head is enveloped in gauze—two or three layers thick, and cut to

the size and shape of a large handkerchief. The tourniquet is slipped over the head, as low down as possible, and then
tightened up. The median tape, having a loop behind through which the tourniquet passes, is laid in the middle line and
tied round the screw on the fixation piece.

The gauze should then be moistened with saline solution or some mild antiseptic, so that it clings tightly to the

underlying scalp and becomes sufficiently translucent to allow of the recognition of any underlying landmarks that may
have been previously mapped out with the scalpel, iodine, silver nitrate, or aniline pencil.

The scalp-flap is then framed by incisions carried down to the bone, through gauze and scalp, in one sweep. The

flap is turned down and covered with gauze. By the adoption of this method hæmorrhage from scalp-vessels is
efficiently controlled and the risk of wound infection is reduced to a minimum.

After the completion of the operation, the scalp-flap is approximated and sewn into position, first by numerous

buried fine silk sutures bringing together the aponeurotic layer of the scalp, and finally by a few silk or salmon-gut
sutures passed through the skin itself. Gauze dressings are applied, the tourniquet loosened, and a roll-gauze bandage

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Hæmorrhage from the bone.

Hæmorrhage from the dural vessels.

quickly applied circumferentially around the head, low down over the forehead and occipital region. This roll bandage in
reality takes the place of the tourniquet, but is, of course, applied with moderate pressure only.

If the wool and bandage now applied over all should include the ears, these two organs should be well covered

with vaseline. Few things are more uncomfortable to the patient than the contact of wool and bandage to the ears.

The tourniquet should be utilized whenever possible. In operations, however, that are conducted near the base of

the skull—subtemporal decompression, cerebellar exploration, &c.—the surgeon, in his effort at hæmostasis, must rely
on the application of digital pressure on either side of the incision, the more careful exposure of the vessels, and the
application of forceps as soon as they are seen or divided, or by the utilization of Vorschütz’s hæmostatic safety-pins.

Other methods of controlling scalp-bleeding are as follows:—
1. Kredel’s hæmostatic sutures, passed with a large curved needle which slides along the bone and emerges about

5 to 7 cm. from the point of introduction. The silk ligatures are then tied over metal plates, so curved as to lie flush with
the surface of the skull in the particular region involved. Four of these plates would be used in the formation of an
osteoplastic flap, one on the distal side of each of the three scalp incisions, and one along the base of the flap.

2. The enclosure of the proposed incision by a running suture which, passing down to the bone, emerges about 1

inch further on, then so to speak repeating itself in part until the whole region is surrounded. The ligatures are then
tightened up. This method takes some time in its application, and presents no advantages over the scalp-tourniquet.

3. The blocking of the main arterial supply—temporal, occipital, and supra-orbital vessels—by modified safety-

pins, mass ligatures, &c. Arterial compression by means of the modified safety-pin as suggested by Vorschütz will be
found most useful in those operations in which the scalp-tourniquet cannot be utilized—subtemporal decompression,
&c.

Severe bleeding may take place from the mastoid and other emissary veins, and

from the open mouths of those abnormally dilated diploic and emissary veins so often encountered in the exposure of an
underlying dural or superficial cerebral tumour. The foramina in the bone, when exposed, must be occluded as quickly
as possible. For this purpose we have the following methods at our disposal—plugging with small bone or wooden
pegs, blockage with minute plugs of cotton-wool, and the utilization of Horsley’s wax, smeared over the part and well
pressed home.

Hæmorrhage may also occur from the bone during trephining, more especially when the operation is conducted

over that part of the anterior division of the middle meningeal artery which runs through a channel in the spheno-parietal
region. Here the disk of bone should be removed as quickly as possible and the channel plugged with pegs, cotton-
wool, or wax.

Oozing from the raw surface of the cut bone is controlled by rubbing in aseptic wax, or by the crushing together of

the inner and outer tables.

In this case the bleeding may occur from three sources, meningeal veins

—often of considerable size when related to neighbouring tumour-formation—the middle meningeal artery, and the
venous sinuses of the brain.

Hæmorrhage from meningeal veins may be arrested by one or other of the following methods:—
1. Gentle pressure as applied either by dry gauze, or wet gauze soaked in saline solution at a temperature between

110 and 115 degrees Fahrenheit.

2. The application of a piece of muscle to the bleeding-point. This method was, I believe, first introduced by Sir

Victor Horsley. Some muscle is usually available for the purpose, usually the temporal muscle. A small portion of
muscle is snipped off, spread out as a flat muscular pad, the bleeding area dried, and the graft quickly applied. It soon
adheres, and usually arrests the hæmorrhage.

3. The application of a ligature. This method is placed last, being the most difficult. It is usually necessary to

underrun the bleeding-point with a fine needle threaded with the finest of silk. It presents the disadvantage in that the
needle may perforate the dura mater and puncture one of the superficial cerebral veins.

FIG. 6. CUSHING’S CLIPS. A, The holder of the clips; B, A clip ready to be applied; C, Two clips applied to

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Hæmorrhage from the superficial vessels of the brain.

Craniectomy.

the middle meningeal artery.

Hæmorrhage from the middle meningeal artery may be controlled by ligature or torsion, and added to these

methods we have one other, recently introduced by Cushing—silver wire ‘clips’. These clips are U-shaped, loaded on
a magazine, picked up as required in the jaws of a specially indented forceps, and clipped on to the vessel—usually one
on either side of the bleeding-point.

Hæmorrhage from venous sinuses is dealt with on p. 150.

This form of hæmorrhage, one of the most

troublesome complications arising in head-operations, most commonly results from hasty or careless opening of the
dura mater. Thus, when the dura is incised in a case of greatly increased intracranial pressure, the brain herniates
suddenly outwards, and the incautious use of the knife will damage one of the dilated superficial cortical veins. The dura
should always be opened with the greatest care, the knife being passed lightly over the membrane till the pia-arachnoid
is exposed, when the dural margins are lifted up with small tenaculum forceps and the membrane slit up with blunt-
pointed scissors or on a grooved director.

In the event of injury, the bleeding may often be controlled by light pressure with dry gauze, or wet gauze wrung

out in hot saline solution as described above. If this fails, a very fine silk ligature may be passed beneath the vessel on
either side of the site of bleeding. This procedure is not easy to accomplish, the tissues are so soft and friable. However,
every effort must be made to arrest the bleeding, for not only does the hæmorrhage obscure the field of operation, but
the presence of a blood-clot beneath the dura mater will lead at a later date to the formation of adhesions between the
various membranes of the brain—a potent cause of headache, epilepsy, &c.

THE OPENING OF THE SKULL

Two methods are adopted in the exposure of meninges and brain—craniectomy and craniotomy.
Craniectomy implies the formation of a scalp-flap, exposure of the bone, trephining of the skull, and enlargement

of the gap to the required size and shape.

Craniotomy implies the formation of a flap of scalp and bone in one, and the exposure of an area of dura and

brain directly proportionate to the size of the bone-flap.

After the application of protective gauze and tourniquet, the scalp-flap is framed according to the

requirements of the case. If the tourniquet is used, the knife is entered at one extremity of the proposed flap, carried
down to the bone—through gauze and scalp in one—and the incision completed in a single sweep. Under other
circumstances, digital pressure is applied to the main flap-supplying vessel, e.g. the temporal artery over the base of the
zygoma, or else Kredel’s clamps or Vorschütz’s hæmostatic safety-pins are passed in such a manner as to control
bleeding from the main supplying vessel. In the event of bleeding, the surgeon goes along quietly, deepening his incision
and seizing each vessel as exposed.

In turning down the scalp-flap it is usually recommended that the pericranium should be included. This is quite

unnecessary, and, under certain circumstances, should certainly be omitted (see p. 129). It should be stripped away
from the underlying bone as required.

FIG. 7. HUDSON’S TREPHINE. Showing the usual method of using the spiral perforator, spiral follower, and

enlarging burr.

The trephining may be carried out with the hand-trephine, or by means of saws, burrs, and trephines driven by

electricity. With the exception of a few words on Hudson’s trephine, I do not propose to discuss the relative
advantages and disadvantages of these mechanically-driven instruments. I hold the opinion that the hand-driven
instrument is sufficiently rapid in its work, that it is infinitely safer, and that the surgeon should accustom and perfect
himself with those instruments which are to him most convenient and most portable. He will not always be conducting
his operations in a perfectly equipped hospital, much of his work will be carried out in the nursing home or in the
country. Whatever method be adopted, the operator should use those instruments to which he is most accustomed.

Hudson’s trephine is shaped after the style of the carpenter’s brace and is fitted with three cutting heads—the

perforator, the follower, and the enlarging burr. It is claimed that injury to the dura and brain is impossible, the
instrument becoming automatically locked so soon as the resistance of the internal table is overcome, a thin film of bone
being pushed in front of the advancing head. I have had the opportunity of using this instrument, and so far as my
experience goes it answers all requirements. Still, I prefer the ordinary hand-trephine so long as it satisfies certain
requirements. It must be of simple mechanism and strong, the handle of good size and shaped to fit the hand, the shaft

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and head so interlocked as to allow of no independent movement, and the hollow head sharply toothed and bevelled
externally, in continuity with the teeth, for a distance of half an inch. The bevelling is so arranged that the actual cutting
process is only effected during supination of the hand and forearm. The pin of the trephine should not project beyond
the cutting edge for a greater distance than about ·2cm. This pin should be readily removable.

FIG. 8. THE HAND-TREPHINE.

The pattern which I am accustomed to use is depicted in Fig. 8. The trephines are kept in three sizes—diameter

1⁄2, 1, and 11⁄2 inches. The intermediate size is used for ordinary trephining, the small one for the formation of the
osteoplastic flap, the large for the removal of a disk of bone which includes within its circumference the area involved in
some depressed and punctured fractures (see p. 133).

FIG. 9.

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